Inspection Reports for Diversicare of Council Grove
400 SUNSET DRIVE, KS, 66846
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 19, 2025, found no deficiencies and confirmed the facility was in compliance with all regulations. Prior inspections showed a pattern of deficiencies related primarily to resident privacy during care, wound care quality, infection prevention and control, and environmental cleanliness, including pest control issues. Several complaint investigations substantiated concerns about dignity, wound care complications, and discharge documentation, but enforcement actions such as fines or license suspensions were not listed in the available reports. Earlier serious findings included an immediate jeopardy related to failure to provide CPR in 2018 and elopement risks in 2016, both of which were addressed with corrective plans. The recent clean inspections following earlier citations suggest the facility has made improvements over time in addressing prior deficiencies.
Deficiencies (last 13 years)
Deficiencies (over 13 years)
12.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
108% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
46 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 19, 2025
Visit Reason
A revisit survey was conducted on 08/19/2025 to verify correction of all previous deficiencies cited on 07/08/2025.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 07/30/2025, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 31, 2025
Visit Reason
An offsite revisit survey was conducted on 07/31/2025 to verify correction of all previous deficiencies cited on 06/17/2025.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 06/18/2025, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Deficiencies corrected: 0
Inspection Report
Plan of Correction
Deficiencies: 5
Jul 30, 2025
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during a prior survey.
Findings
The plan addresses multiple deficiencies including resident privacy during dressing changes, safe and clean environment, quality of wound care, infection prevention and control, and effective pest control. The facility outlines corrective actions, staff education, audits, and ongoing monitoring to ensure compliance.
Severity Breakdown
D: 1
E: 3
G: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Resident privacy was not adequately maintained during dressing changes. | D |
| Facility environment issues including soiled seating and furniture requiring replacement. | E |
| Quality of care concerns related to wound care and psychosocial needs. | G |
| Infection prevention and control deficiencies including clean dressing changes and hand hygiene. | E |
| Ineffective pest control program with pest presence in resident rooms. | E |
Report Facts
Residents audited weekly for wound care: 5
Residents audited weekly for infection control: 5
Residents audited weekly for dressing change privacy: 5
Environmental audits per week: 3
Room pest audits per week: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Frohlich | Administrator | Administrator who submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Tamara Wyss | Person who added and modified the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 5
Jul 8, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint investigations (KS00196358, KS00196222, KS00196202, KS00196134, KS00193119, KS00195995).
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity and privacy, failure to maintain a clean and homelike environment, inadequate wound care resulting in maggot infestation, ineffective infection prevention and control practices, and failure to maintain an effective pest control program.
Complaint Details
The inspection was triggered by multiple complaint investigations identified by numbers KS00196358, KS00196222, KS00196202, KS00196134, KS00193119, KS00195995.
Severity Breakdown
SS = D: 1
SS = E: 3
SS = G: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to treat residents in a dignified manner by providing privacy during personal care. | SS = D |
| Failure to maintain a clean, comfortable, and homelike environment, including strong urine odor and unclean furniture. | SS = E |
| Failure to provide adequate wound care for Resident 1, resulting in maggot infestation in wounds. | SS = G |
| Failure to maintain an effective infection prevention and control program, including inadequate hand hygiene and cleaning practices. | SS = E |
| Failure to maintain an effective pest control program, evidenced by presence of flies and maggots in resident rooms. | SS = E |
Report Facts
Resident census: 46
Residents reviewed for wounds: 2
Residents potentially affected by infection control deficiency: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Performed dressing changes without proper hand hygiene and privacy measures; observed removing maggots from wounds. |
| Administrative Nurse D | Administrative Nurse | Confirmed expectations for privacy, hand hygiene, and wound care; unaware of continued maggot presence; provided statements on infection control and wound care. |
| Certified Nurse Aide M | Certified Nurse Aide | Assisted resident R3 and requested housekeeping to clean saturated recliner. |
| Certified Nurse Aide N | Certified Nurse Aide | Assisted resident R3 with toileting and transferring. |
| Housekeeping Staff U | Housekeeping Staff | Shampooed recliner seat but did not use disinfectant chemicals. |
| Consultant GG | Consultant | Stated nursing staff cleaned bodily fluids and housekeeping disinfected surfaces; acknowledged hot water alone is not a disinfectant. |
| Physician HH | Physician | Unaware of continued maggot presence; stated maggots not harming wound and noted fly problem. |
| Administrative Staff A | Administrative Staff | Reported fly mitigation efforts and concerns about flies; communicated with housekeeping management for training. |
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 18, 2025
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a previously identified deficiency related to an involuntary discharge notice.
Findings
The center rescinded the discharge notice on April 8th, 2025, and provided education to leadership on the importance of thorough clinical documentation to justify involuntary discharges. The Administrator will review clinical documentation daily prior to discharge notices, and findings will be reported monthly to the QAPI Committee for three months.
Deficiencies (1)
| Description |
|---|
| Involuntary discharge notice issued without sufficient clinical documentation to support the discharge. |
Report Facts
Date discharge notice rescinded: Apr 8, 2025
Plan of Correction completion date: Jun 18, 2025
Reporting timeframe: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Frohlich | Administrator | Administrator who submitted the Plan of Correction and responsible for reviewing clinical documentation. |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Jun 12, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint investigations (KS00195730, KS00194193, KS00193965, and KS00192848) regarding the facility's handling of an involuntary discharge of a resident.
Findings
The facility initiated a 30-day involuntary discharge for Resident 1 (R1) without sufficient clinical documentation to justify the discharge. The resident's medical record lacked evidence that the resident's needs could not be met or that the resident endangered others. Behavioral issues were documented but interventions were not adequately recorded. The facility failed to report a resident-to-resident threat as required and did not have a policy related to involuntary discharge.
Complaint Details
The visit was complaint-related, triggered by multiple complaint investigations (KS00195730, KS00194193, KS00193965, KS00192848). The complaint involved inappropriate discharge practices and failure to properly document and manage resident behaviors and discharge planning.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Involuntary discharge of Resident 1 without sufficient clinical justification or documentation. | SS=D |
Report Facts
Resident census: 52
Involuntary discharge notice period: 30
Percentage of care refusal: 70
Discharge date: Mar 10, 2025
Date of complaint withdrawal request: Apr 12, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Reported on discharge planning, family involvement, and failure to report resident-to-resident abuse. | |
| Administrative Nurse D | Reported on resident's refusal of care and behavioral issues. | |
| Certified Medication Aide R | Certified Medication Aide | Reported on resident's behavior towards staff. |
| CNA M | Certified Nursing Assistant | Reported on resident's yelling behaviors toward staff. |
| Administrative Nurse E | Reported on resident's verbal aggression and threats towards other residents. |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 22, 2024
Visit Reason
An offsite revisit survey was conducted on 10/22/24 for all previous deficiencies cited on 08/28/24 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 10/03/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 11
Aug 28, 2024
Visit Reason
The inspection was a Health Resurvey and investigation of complaint #189595 related to resident dignity and care.
Findings
The facility failed to maintain resident dignity related to urinary catheter care, failed to ensure reasonable accommodation for a resident's wheelchair needs, failed to notify a resident's representative of a change in condition and treatment for scabies, failed to revise care plans timely for multiple residents, failed to provide safe transfer techniques, failed to provide sanitary respiratory care, failed to post accurate nurse staffing information, failed to prevent unnecessary medications related to bowel management, and failed to submit accurate payroll-based journal staffing data.
Complaint Details
The visit was triggered by complaint #189595 regarding resident dignity and care.
Severity Breakdown
SS=D: 7
SS=E: 1
SS=C: 1
SS=F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to show respect and dignity to residents by not covering urinary catheters and leg bags in common areas. | SS=D |
| Failure to ensure reasonable accommodation of resident's wheelchair needs and lack of follow-up on recommendations. | SS=D |
| Failure to notify resident's representative of change in condition and new treatment for scabies infestation. | SS=D |
| Failure to review and revise care plans for residents related to scabies infection, urinary catheter care, and catheter anchoring device. | SS=E |
| Failure to provide safe transfer techniques for a resident at risk for falls. | SS=D |
| Failure to provide sanitary catheter care and prevent urinary tract infections. | SS=D |
| Failure to analyze voiding diary and develop personalized toileting plan, and failure to provide PRN bowel medications. | SS=D |
| Failure to provide sanitary respiratory care and proper nebulizer treatment administration. | SS=D |
| Failure to post accurate, publicly accessible nurse staffing information daily. | SS=C |
| Failure to ensure residents remained free from unnecessary medications related to failure to administer PRN bowel medications. | SS=D |
| Failure to electronically submit complete and accurate direct care staffing information to CMS, including accurate weekend staffing data. | SS=F |
Report Facts
Resident census: 43
Residents sampled: 14
Days without bowel movement: 5
Days without bowel movement: 4
BIMS score: 6
BIMS score: 4
BIMS score: 15
BIMS score: 3
BIMS score: 14
BIMS score: 14
BIMS score: 7
BIMS score: 0
Oxygen flow rate: 2
Medication dose: 0.5
Medication dose: 2.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Interviewed regarding expectations for catheter care, transfer safety, notification of changes, staffing, and respiratory care. |
| Certified Nurse Aide N | Certified Nurse Aide | Interviewed regarding catheter leg bag care and dignity covers. |
| Certified Nurse Aide M | Certified Nurse Aide | Interviewed regarding availability of dignity bags for catheter leg bags. |
| Certified Nurse Aide P | Certified Nurse Aide | Observed and interviewed regarding resident transfers and catheter anchoring device. |
| Certified Nurse Aide R | Certified Nurse Aide | Assisted resident with dressing and confirmed scabies treatment. |
| Certified Medication Aide Q | Certified Medication Aide | Observed administering nebulizer treatment and cleaning equipment. |
| Licensed Nurse G | Licensed Nurse | Interviewed regarding bowel management and PRN medication administration. |
| Therapy Consultant HH | Therapy Consultant | Interviewed regarding wheelchair assessment and recommendations. |
| Administrative Staff A | Administrative Staff | Interviewed regarding wheelchair assessment follow-up and staffing reporting. |
Inspection Report
Plan of Correction
Deficiencies: 10
Aug 28, 2024
Visit Reason
This document is a Plan of Correction submitted by Diversicare of Council Grove in response to deficiencies cited during a survey conducted on August 28, 2024.
Findings
The plan addresses multiple deficiencies related to resident dignity/privacy, wheelchair accommodations, notification of representatives, care plan updates, safe transfer techniques, medication administration, staffing data accuracy, and other care practices. The facility has implemented reeducation, audits, and ongoing monitoring to ensure compliance and correction of cited deficiencies.
Severity Breakdown
D: 7
E: 1
C: 1
F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Inadequate use of catheter privacy bags and lap coverings for residents #19 and #41 | D |
| Inadequate accommodations for resident #18's wheelchair needs | D |
| Failure to notify resident #18's chosen representative of current condition and treatment changes | D |
| Care plans for residents #8, #18, #19, and #41 not updated timely | E |
| Resident #19 not evaluated or assisted properly for safe transfer | D |
| Resident #95 not provided a three-day voiding diary and personalized care plan; sanitary urinary catheter care issues for resident #19 | D |
| Resident R39 not provided sanitary care related to aerosolized medication administration | D |
| Nursing staffing information not posted daily or accurately | C |
| Residents #12 and #27 not properly evaluated for as needed medications and medication administration | D |
| Payroll Based Journal data incomplete or inaccurate, especially weekend staffing data | F |
Report Facts
Audit frequency: 5
Audit frequency: 4
Audit frequency: 1
Audit duration: 4
Audit duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brad Fischer | Administrator | Administrator who submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 2, 2023
Visit Reason
An offsite revisit survey was conducted on 02/02/23 to verify correction of all previous deficiencies cited on 12/05/22.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 01/11/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Re-Inspection
Census: 42
Deficiencies: 7
Dec 5, 2022
Visit Reason
The inspection was a Health Resurvey to assess compliance with health and safety regulations at Diversicare of Council Grove.
Findings
The facility was found deficient in multiple areas including failure to provide a safe, clean, and comfortable environment, inadequate assistance with activities of daily living, failure to prevent decrease in range of motion, inconsistent medication administration, inappropriate use of antipsychotic medication without proper diagnosis, lack of required Quality Assessment and Assurance committee attendance, and failure to maintain effective infection prevention and control practices.
Severity Breakdown
SS=E: 1
SS=D: 4
SS=F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide a safe, clean, comfortable and homelike environment in certain areas, including issues with room doors and furniture. | SS=E |
| Failed to provide shaving for dependent resident, placing resident at risk of impaired comfort and dignity. | SS=D |
| Failed to prevent decrease in range of motion/mobility for a resident with contractures. | SS=D |
| Failed to ensure drug regimen was free from unnecessary drugs due to inconsistent medication administration for two residents. | SS=D |
| Failed to provide appropriate diagnosis for antipsychotic medication for a resident. | SS=D |
| Lacked evidence that required members attended Quality Assessment and Assurance Committee meetings at least quarterly. | SS=F |
| Failed to maintain an effective infection prevention and control program, including failure to identify high COVID transmission rates and failure of staff to wear masks. | SS=F |
Report Facts
Census: 42
Sample size: 12
Medication missed doses: 18
Medication missed doses: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Verified findings related to environment, medication administration, and infection control; provided statements on facility policies and staff practices. |
| Licensed Nurse G | Licensed Nurse | Verified medication administration issues and resident care needs. |
| Certified Nurse Aide N | Certified Nurse Aide | Reported on resident care including shaving assistance. |
| Certified Nurse Aide M | Certified Nurse Aide | Reported on resident care including range of motion and splint use. |
| Maintenance Staff U | Maintenance Staff | Verified environmental deficiencies related to maintenance work orders. |
| Administrative Staff A | Administrative Staff | Provided information on Quality Assurance meeting attendance procedures. |
Inspection Report
Plan of Correction
Deficiencies: 7
Dec 5, 2022
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a survey conducted on December 5, 2022.
Findings
The Plan of Correction addresses multiple deficiencies including environmental issues, resident personal care, medication administration, restorative services, infection control, and quality assurance processes. The facility outlines corrective actions, staff re-education, audits, and ongoing monitoring to ensure compliance and improvement.
Severity Breakdown
E: 1
D: 4
F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Resident #7’s door repaired and latches easily; Resident #10’s transitioning floor casing attached; recliner replaced; environmental rounds and audits initiated. | E |
| Residents assessed and provided shaving and nail care; direct care team re-educated; resident interviews planned. | D |
| Resident #4’s palm protector placed and passive ROM provided; therapy reassessments and staff education on restorative programs. | D |
| Residents #28 and #29 received medications; missed medications addressed; staff educated on medication documentation. | D |
| Resident #29’s medication indications reviewed and updated; nursing staff re-educated on medication indication documentation. | D |
| Quality Assurance Assessment (QAA) completed; administrative staff re-educated on attendance documentation; audits planned. | F |
| Staff immediately wore masks due to increased community transmission; education on mask use and infection control; monitoring and root cause analysis planned. | F |
Report Facts
Audit frequency: 5
Audit duration: 3
Audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brad Fischer | Administrator | Administrator who submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Lanae Workman | Person who added the Plan of Correction | |
| Felicia Majewski | Person who modified the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 1, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-07-27.
Findings
All deficiencies have been corrected as of the compliance date of 2022-08-17, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiency citation date: Jul 27, 2022
Compliance date: Aug 17, 2022
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Jul 27, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaint investigation numbers KS00172746, KS00172349, and KS00171506.
Findings
The facility failed to provide one resident with food choices based on his identified preferences, despite documented dietary orders and care plans. The resident expressed dissatisfaction with repetitive meals and lack of variety, particularly the frequent serving of hot dogs and limited alternate meal options.
Complaint Details
The visit was complaint-related, investigating complaints identified by numbers KS00172746, KS00172349, and KS00171506.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide food that accommodates resident allergies, intolerances, and preferences as evidenced by not providing one resident with food choices based on his identified preferences. | SS=D |
Report Facts
Census: 40
BIMS score: 15
BIMS score: 14
Dietary order: 6
Dietary order date: Aug 30, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff BB | Reported on food choices and alternatives, confirmed meal ticket process, and stated that food choices were a corporate decision. | |
| Consultant GG | Reported food concerns should be communicated to the dietary manager and confirmed alternate meal choices. | |
| Certified Medication Aide R | Certified Medication Aide | Informed resident about menu options and alternatives, and reported on residents' meal choices. |
| Licensed Nurse G | Licensed Nurse | Provided information about resident's eating habits and meal preferences. |
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 27, 2022
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a survey conducted on July 27, 2022.
Findings
The facility identified a deficiency related to accommodating resident #2's food preferences and the dining services provided to other residents. The plan includes updating menus, conducting audits, and implementing a Person Centered Dining Approach to ensure compliance.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident #2 has had food provided that accommodates his choices based on his identified preferences. | D |
Report Facts
Audit frequency: 3
Compliance date: Aug 17, 2022
Inspection Report
Follow-Up
Deficiencies: 0
May 21, 2021
Visit Reason
An offsite revisit was conducted on 05/21/21 for all previous deficiencies cited on 03/02/21 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 03/24/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 3
Mar 24, 2021
Visit Reason
This plan of correction is submitted in response to deficiencies cited during a prior survey to assure correction and continued compliance with regulations.
Findings
The facility identified deficiencies related to wheelchair foot pedals, bladder incontinence assessments, and dietary recommendations for residents. Corrective actions include staff education, resident assessments, audits, and ongoing monitoring to ensure compliance.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Resident #24’s wheelchair had foot pedals placed; all wheelchair users assessed for foot pedal use to assist during staff transport. | D |
| Resident #34 assessed for increased urinary incontinence with three day voiding pattern completed; all residents with bladder incontinence to have assessments on admission, quarterly, and upon status change. | D |
| Resident #37’s dietary recommendations implemented with weekly weighing; all residents at risk for weight loss to be weighed weekly and dietary recommendations followed. | D |
Report Facts
Residents audited weekly: 5
Audit frequency: 4
Audit duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brad Fischer | Administrator | Submitted the plan of correction |
Inspection Report
Re-Inspection
Census: 39
Deficiencies: 3
Mar 2, 2021
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with previously cited deficiencies and assess the facility's corrective actions.
Findings
The facility was found deficient in three areas: failure to provide wheelchair foot pedals to prevent accidents for a high fall-risk resident; failure to reassess and provide appropriate services for increased urinary incontinence for another resident; and failure to provide timely weight loss interventions and follow-up for a resident with significant weight loss.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to evaluate and provide wheelchair foot pedals to prevent accidents for Resident 24, a high fall-risk resident with severe cognitive impairment. | SS=D |
| Failed to reassess Resident 34 for increased urinary incontinence after hospitalization and provide appropriate treatment and services. | SS=D |
| Failed to provide timely weight loss interventions and follow-up for Resident 37 who experienced significant weight loss post hospital admission. | SS=D |
Report Facts
Census: 39
Sample size: 12
Distance wheelchair pushed: 140
Weight loss percentage: 11.33
Weight loss percentage: 6.7
Weight measurements: 150
Weight measurements: 123.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Verified staff should place Resident 24's feet on foot pedals and confirmed failure to perform timely weight monitoring and follow-up for Resident 37. | |
| Certified Nurse Aide P | CNA | Stated Resident 24 was high fall risk and required wheelchair for mobility. |
| Licensed Nurse I | LN | Stated Resident 24 was high fall risk and required extensive staff assistance. |
| Certified Nurse Aide M | CNA | Observed Resident 34 and assisted with toileting. |
| Certified Nurse Aide N | CNA | Reported Resident 34 used call light for toileting assistance and was incontinent at times. |
| Licensed Nurse E | LN | Stated Resident 34 needed another bladder assessment and confirmed frequent incontinence. |
| Dietary Staff BB | DS | Verified dietician recommendations and feeding observations for Resident 37. |
| Licensed Nurse G | LN | Observed Resident 37 receiving nutritional supplements. |
| Certified Nurse Aide O | CNA | Assisted Resident 37 with eating a banana. |
| Licensed Nurse H | LN | Explained Resident 37 received supplements due to high activity level. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by Kansas Department for Aging and Disability Services (KDADS) for the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 16, 2020
Visit Reason
The document is a Plan of Correction submitted in response to a COVID and emergency preparedness survey conducted on 12/16/2020 at Diversicare Council Grove.
Findings
The survey was deficiency free, indicating no deficiencies were found related to COVID and emergency preparedness during the inspection.
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 13, 2020
Visit Reason
An off-site revisit was conducted to verify correction of all previous deficiencies cited on 07/13/2020.
Findings
All deficiencies have been corrected as of the compliance date of 07/31/2020 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 13, 2020
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a survey conducted on 07/13/2020 at Diversicare Council Grove.
Findings
The plan addresses a deficiency related to the failure to provide and offer face masks or tissues to residents prior to the provision of cares, affecting five residents and potentially others. The facility has implemented training and auditing procedures to ensure compliance.
Deficiencies (1)
| Description |
|---|
| Failure to provide and offer face masks or tissues to residents prior to provision of cares. |
Report Facts
Residents affected: 5
Audit frequency: 4
Audit frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Paula Gant | Administrator | Submitted the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Jul 13, 2020
Visit Reason
The inspection was conducted as a complaint investigation (#153486) to evaluate infection prevention and control practices related to COVID-19.
Findings
The facility failed to follow CMS and CDC recommendations by not providing or offering face masks or tissues to five of eight sampled residents prior to direct care, increasing the risk of COVID-19 transmission among residents.
Complaint Details
The complaint investigation (#153486) found that the facility did not comply with infection control practices to prevent COVID-19 transmission, specifically failing to provide face masks or tissues to residents during care.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide or offer face masks or tissues to residents prior to direct care, increasing risk of COVID-19 transmission. | SS=F |
Report Facts
Resident census: 56
Sample size: 8
Residents without masks or tissues during care: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA O | Certified Nurse Aide | Named in findings for not offering face mask or tissue to Resident 1 during care. |
| CNA P | Certified Nurse Aide | Named in findings for not offering face mask or tissue to Resident 1 during care and reporting mask policies. |
| CNA N | Certified Nurse Aide | Named in findings for not offering face mask or tissue to Resident 1 during care. |
| CNA M | Certified Nurse Aide | Named in findings for not offering face mask or tissue to Resident 1 during care and reporting mask policies. |
| License Nurse G | Licensed Nurse | Named in findings for failing to ensure Resident 6 wore mask properly and not providing mask to Resident 8. |
| CNA S | Certified Nurse Aide | Named in findings for not offering face mask or tissue to Residents 5 and 8 during care. |
| CNA R | Certified Nurse Aide | Named in findings for not offering face mask or tissue to Resident 3 during care. |
| CNA T | Certified Nurse Aide | Reported mask wearing policies for residents. |
| LN H | Licensed Nurse | Reported mask wearing policies for residents. |
| Administrative Nurse D | Administrative Nurse | Reported on mask wearing compliance and challenges among residents. |
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 24, 2020
Visit Reason
The document is a Plan of Correction submitted in response to a COVID-19 survey conducted on 06/24/2020.
Findings
The facility was found to be deficiency free during the COVID-19 survey conducted on 06/24/2020.
Deficiencies (1)
| Description |
|---|
| DEFICIENCY FREE COVID 19 SURVEY |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 24, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Kansas Department on Aging and Disability (KDADS) to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 12, 2019
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2019-05-30.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 2019-06-21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiency citation date: May 30, 2019
Compliance date: Jun 21, 2019
Inspection Report
Plan of Correction
Deficiencies: 8
May 30, 2019
Visit Reason
This document is a Plan of Correction submitted by Diversicare of Council Grove in response to deficiencies cited during a survey conducted on 2019-05-30.
Findings
The plan outlines corrective actions for multiple deficiencies including proper use of CMS 10055 forms for discharge notices, delivery of Bed Hold Policy to residents and next of kin, updating activity preferences and care plans, bowel protocol adherence, psychotropic medication documentation, kitchen sanitation, antibiotic stewardship, and environmental cleaning.
Severity Breakdown
E: 3
D: 4
F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to properly provide CMS 10055 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage to residents being discharged from skilled services. | E |
| Failure to provide and document delivery of the facility's Bed Hold Policy to residents and next of kin upon discharge, transfer, or leave. | D |
| Activity preferences and care plans not reviewed or updated as indicated for resident #58. | D |
| Failure to follow bowel protocol and properly document bowel movements for residents #38 and #53. | D |
| Lack of documentation of non-pharmacological interventions prior to administration of PRN psychotropic medications for resident #44. | D |
| Unsanitary conditions in kitchen including dirty trash can, oven racks with black substance, freezer frost buildup, worn cutting boards and cooking utensils, and sticky refrigerator shelf. | F |
| Failure to ensure diagnosis is documented for all antibiotics ordered as part of the Antibiotic Stewardship Program. | F |
| Accumulation of grime, dirt, and food debris on kitchen floors and pipes, requiring deep cleaning and new cleaning schedules. | E |
Report Facts
Audit frequency: 3
Audit frequency: 4
Date of survey: May 30, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul Agant | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 8
May 30, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and investigation of complaints #135251 and #136379.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare beneficiary notices, failure to provide bed-hold notices upon hospital transfer, inadequate activities programming for dependent residents, failure to monitor and administer bowel medications properly, failure to document non-pharmacological interventions before PRN psychotropic medication use, unsanitary food preparation and kitchen conditions, and inadequate antibiotic stewardship monitoring.
Complaint Details
The inspection was triggered by complaints #135251 and #136379.
Severity Breakdown
SS=D: 4
SS=F: 2
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide 4 residents with the appropriate Beneficiary Protection Notification CMS form 10055 to ensure the residents' right to appeal Medicare part A services upon discontinuation and potential financial considerations. | — |
| Failed to complete a bed-hold notice for 1 resident upon admission to the hospital. | SS=D |
| Failed to provide an ongoing program of activities designed to meet the interests of a dependent resident. | SS=D |
| Failed to monitor bowel movements and follow physician's prescribed bowel protocol medications for 2 residents reviewed for unnecessary medications. | SS=D |
| Failed to document non-pharmacological interventions before administration of a PRN anti-anxiety medication for 1 resident. | SS=D |
| Failed to store, prepare and serve food under sanitary conditions in 1 of 2 kitchens, including issues with trash cans, oven racks, freezer frost buildup, cutting boards, cookware, knives, and refrigerator cleanliness. | SS=F |
| Failed to utilize an antibiotic stewardship program that included monitoring of residents' antibiotic usage, with infection control logs lacking infection diagnoses and incomplete antibiotic stewardship tracking. | SS=F |
| Failed to provide a sanitary environment for residents and staff in 2 facility kitchens, including accumulation of grime, dirt, food debris on floors and under sinks. | SS=E |
Report Facts
Residents reviewed for Medicare liability: 4
Residents reviewed for hospitalization: 2
Residents reviewed for activities: 2
Residents reviewed for unnecessary medications: 6
Residents reviewed for unnecessary psychotropic medications: 5
Number of cutting boards with deep grooves: 8
Number of antibiotics listed in infection control log: 6
Number of antibiotics listed in infection control log: 7
Number of antibiotics listed in infection control log: 12
Number of antibiotics listed in infection control log: 10
Number of antibiotics listed in infection control log: 18
Number of antibiotics listed in infection control log: 6
Number of antibiotics listed in infection control log: 6
Number of antibiotics listed in infection control log: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Business Office Staff | Named in findings related to failure to provide Medicare beneficiary protection notification forms and bed-hold notices. |
| Staff B | Administrative Staff | Named in findings related to failure to complete bed-hold notices and antibiotic stewardship program. |
| Staff E | Dietary Manager | Named in findings related to kitchen sanitation and cleaning schedules. |
| Staff D | Activity Staff | Named in findings related to activities programming deficiencies. |
| Staff I | Licensed Nursing Staff | Named in findings related to bowel movement monitoring and medication administration. |
| Staff J | Consultant Staff | Named in findings related to bowel movement monitoring and psychotropic medication documentation. |
| Staff K | Licensed Staff | Named in findings related to documentation of interventions before PRN medication administration. |
| Staff Q | Direct Care Staff | Named in findings related to bowel movement documentation. |
| Staff R | Direct Care Staff | Named in findings related to bowel movement documentation. |
| Staff T | Dietary Staff | Named in findings related to kitchen sanitation and floor cleaning. |
| Staff S | Licensed Staff | Named in findings related to bowel movement documentation and medication administration. |
| Administrative Staff C | Infection Control Program Staff | Named in findings related to antibiotic stewardship program. |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 3, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 08/08/2018.
Findings
All deficiencies have been corrected as of the compliance date of 08/31/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 6
Aug 31, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions to be taken to assure compliance with regulations.
Findings
The plan details multiple corrective actions addressing environmental repairs, resident care concerns, and staff education to resolve identified deficiencies. The facility commits to ongoing monitoring and review through Quality Assurance and Performance Improvement (QAPI) meetings.
Severity Breakdown
E: 1
D: 4
F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Environmental repairs including removal of duct tape, repair and painting of window sills, grout replacement around toilet bases, and replacement of damaged wheelchair arm rests. | E |
| Customer Concern Form completed regarding resident's concern with staff member; staff and resident meetings planned for resolution. | D |
| Resident with broken glasses taken to eye doctor; facility-wide assessment of glasses and staff education planned. | D |
| Resident lift status reassessed and care plans updated; staff education and audits planned. | D |
| Resident bowel movement status reviewed with interventions; staff education and audits planned. | D |
| Mandatory all-staff in-service on infection prevention and control; audits and monitoring planned. | F |
Report Facts
Date for corrective actions completion: Aug 31, 2018
Date of resident eye exam: Aug 14, 2018
Date new glasses received: Aug 17, 2018
Inspection Report
Re-Inspection
Census: 62
Deficiencies: 6
Aug 8, 2018
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements related to safe, clean, and comfortable environment, grievance handling, treatment devices, accident prevention, drug regimen, and infection control.
Findings
The facility failed to maintain a sanitary, orderly, and comfortable environment in multiple resident rooms and utility areas, failed to properly investigate and resolve a resident grievance regarding staff behavior, failed to assist a resident with repairing broken glasses, failed to ensure adequate assistance during resident transfers, failed to monitor and administer medications for constipation appropriately, and failed to maintain an effective infection control program with proper cleaning and storage of personal hygiene and care equipment.
Severity Breakdown
SS=E: 1
SS=D: 4
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to maintain a sanitary, orderly, and comfortable interior in 13 resident rooms, TV area, clean and dirty utility rooms. | SS=E |
| Failure to act upon a resident grievance regarding staff rudeness and failure to follow grievance procedures. | SS=D |
| Failure to assist a resident with repairing/replacing broken glasses. | SS=D |
| Failure to ensure adequate assistance with mechanical lift transfers for a resident requiring 2 staff. | SS=D |
| Failure to monitor and administer medications for constipation for multiple residents, resulting in unnecessary drug usage. | SS=D |
| Failure to establish and maintain an effective infection control program, including improper cleaning and storage of personal hygiene and care equipment. | SS=F |
Report Facts
Census: 62
Resident rooms with deficiencies: 13
Residents reviewed for visual needs: 1
Residents reviewed for activities of daily living: 3
Residents reviewed for unnecessary medication usage: 5
Days without bowel movement: 6
Days without bowel movement: 4
Days without bowel movement: 3
Number of community electric razors with hair buildup: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff O | Direct care staff | Named in grievance finding regarding rude behavior to resident #4 |
| Administrative nursing staff E | Administrative nursing staff | Involved in grievance investigation and acknowledged failure to document |
| Social service staff X | Social service staff | Discussed grievance handling and glasses repair responsibilities |
| Licensed nursing staff G | Licensed nursing staff | Reported on resident #15 bowel movement and glasses condition |
| Direct care staff P | Direct care staff | Observed transferring resident #18 without required assistance |
| Licensed nursing staff J | Licensed nursing staff | Reported resident #18 transfer requirements |
| Administrative nursing staff D | Administrative nursing staff | Reported on grievance and transfer assessment failures |
| Licensed nursing staff I | Licensed nursing staff | Reported on transfer assessment and bowel movement monitoring |
| Licensed nursing staff H | Licensed nursing staff | Reported on resident #28 glasses condition |
| Administrative nursing staff F | Administrative nursing staff | Verified infection control deficiencies and cleaning/storage failures |
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 8, 2018
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be a 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 08/31/2018.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be a 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Named as contact person regarding the inspection findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 2
Feb 23, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report.
Findings
The plan indicates that the cited deficiencies F0000 and F678-K were past noncompliance issues for which no plan of correction was required.
Deficiencies (2)
| Description |
|---|
| Past noncompliance: no plan of correction required. |
| Past noncompliance: no plan of correction required. |
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Feb 23, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#126709) regarding the facility's failure to provide CPR according to a resident's advanced directives.
Findings
The facility failed to provide CPR to a resident with a full code status when found unresponsive, placing the resident in immediate jeopardy. Staff did not verify the resident's code status or initiate CPR as required by policy and the resident's advanced directives. Training deficiencies related to CPR and code status determination were identified and addressed.
Complaint Details
Complaint investigation #126709 found the facility failed to provide CPR to resident #1 who had a full code status, resulting in immediate jeopardy. Staff did not check code status or initiate CPR, and training on CPR versus DNR was lacking.
Severity Breakdown
SS=K: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide CPR according to resident's advanced directives when found unresponsive. | SS=K |
Report Facts
Census: 61
Residents with full code status: 18
Residents sampled for CPR review: 3
Date of resident discharge due to death: Feb 16, 2018
Date of staff education completion: Feb 17, 2018
Date of mock CPR drills: Feb 20, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Direct Care Staff | Witnessed resident unresponsive but did not initiate CPR |
| Staff F | Licensed Nursing Staff | Reported resident's code status location and CPR certification of night staff |
| Staff E | Licensed Nursing Staff | Assessed resident and found no vital signs; did not check code status prior |
| Staff H | Direct Care Staff | Reported staff called nurse upon finding resident unresponsive |
| Staff D | Licensed Nursing Staff | Reported code status location in resident chart |
| Staff C | Licensed Nursing Staff | Reported procedure for verifying code status and initiating CPR |
| Staff B | Administrative Nursing Staff | Interviewed regarding code status procedures and training |
| Staff I | Administrative Nursing Staff | Interviewed regarding code status procedures and training |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Feb 23, 2018
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted Immediate Jeopardy and Past Non-compliance to resident health or safety for F678, CFR 483.24(a)(3).
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Non-compliance with participation requirements constituting Immediate Jeopardy and Past Non-compliance for F678, CFR 483.24(a)(3). | Immediate Jeopardy |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paula Gant | Administrator | Named as facility administrator in the report. |
| Caryl Gill | Complaint Coordinator | Signed the report as Complaint Coordinator. |
Inspection Report
Follow-Up
Deficiencies: 0
Feb 15, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.20(g)-(j), 483.45(f)(1), 483.60(i)(1)-(3), and 483.45(b)(2)(3)(g)(h) were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 1
Feb 15, 2017
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the date such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency related to regulation 28-39-158(a) was corrected as of 02/15/2017. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 28-39-158(a) previously cited and now corrected |
Inspection Report
Re-Inspection
Census: 62
Deficiencies: 2
Jan 18, 2017
Visit Reason
The inspection was a Health Licensure Resurvey to assess compliance with dietary services regulations.
Findings
The facility failed to provide a full-time certified dietary manager and lacked a policy regarding the requirements for a certified dietary manager. The dietary manager on site was not yet certified, with training expected to be completed in December 2017.
Deficiencies (2)
| Description |
|---|
| Failure to provide a full-time certified dietary manager for the residents of the facility. |
| Failure to provide a policy regarding the requirements for a certified dietary manager. |
Report Facts
Census: 62
Inspection Report
Re-Inspection
Deficiencies: 1
Jan 18, 2017
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective February 15, 2017.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found were 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter and contact person for questions concerning the information in the letter. |
Inspection Report
Follow-Up
Deficiencies: 1
Jan 5, 2017
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that the previously cited deficiency with ID Prefix F0323 related to regulation 483.25(h) was corrected as of 11/29/2016. No other deficiencies or uncorrected issues were noted.
Deficiencies (1)
| Description |
|---|
| Deficiency with ID Prefix F0323 related to regulation 483.25(h) |
Report Facts
Deficiency correction date: Nov 29, 2016
Inspection Report
Plan of Correction
Deficiencies: 1
Nov 29, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at the facility.
Findings
The plan addresses elopement risk assessments and interventions, window security, staff education on elopement policy, and ongoing audits and drills to ensure compliance and resident safety.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as DVC Council Grove complaint 11282016.
Deficiencies (1)
| Description |
|---|
| Resident #1 was assessed and care plan reviewed to ensure appropriate interventions; windows secured; wander guard system checked; elopement risk assessments updated and care plans revised accordingly. |
Report Facts
Audit frequency: 7
Elopement drills frequency: 12
Quarterly assessments: 4
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Nov 28, 2016
Visit Reason
The inspection was conducted as a partial extended complaint investigation (#107570) related to the facility's failure to ensure adequate supervision to prevent a resident's elopement.
Findings
The facility failed to ensure that a resident with dementia and exit-seeking behavior received adequate supervision to prevent elopement. The resident exited the facility through a window multiple times without staff knowledge, including a successful elopement on 10/29/16, placing the resident in immediate jeopardy. The facility lacked updated elopement assessments and interventions after these incidents.
Complaint Details
Partial extended complaint investigation #107570. The complaint was substantiated as the facility failed to prevent elopement of a cognitively impaired resident with exit-seeking behavior.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident environment remained free of accident hazards and to provide adequate supervision to prevent elopement of resident #1. | D |
Report Facts
Resident census: 57
Distance traveled by resident: 651
Distance traveled by resident: 635
Temperature: 69.1
Time outside facility: 25
Staff check interval: 30
Date of staff in-service: Nov 2, 2016
Date of completion of all staff in-service: Nov 18, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Reported observations about window conditions and resident's elopement details. | |
| Administrative nursing staff E | Reported resident's exit-seeking behavior and window security measures. | |
| Community member KK | Found resident outside the facility after elopement and notified staff. | |
| Licensed nursing staff H | Reported resident's wandering behavior and staff check frequency. | |
| Direct care staff O | Reported resident was at risk for elopement and staff check times. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Nov 28, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the facility was not in substantial compliance and that conditions constituted immediate jeopardy to resident health or safety from August 13, 2016 through November 18, 2016 for F323, "J", CFR 483.25(h). Enforcement remedies including denial of payment for new admissions were imposed.
Severity Breakdown
immediate jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Noncompliance with F323, "J", CFR 483.25(h) constituting immediate jeopardy to resident health or safety. | immediate jeopardy |
Report Facts
Denial of payment effective date: Dec 20, 2016
Recommended provider agreement termination date: May 28, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paula Gant | Administrator | Facility administrator named in the report. |
| Caryl Gill | RN, BSN, Complaint Coordinator | Signed the report as Complaint Coordinator. |
Inspection Report
Life Safety
Deficiencies: 1
Jul 13, 2016
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be at 'F' level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'F' level indicating no harm with potential for more than minimal harm but not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Oct 13, 2016
Provider agreement termination date: Jan 13, 2017
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Re-Inspection
Deficiencies: 1
Aug 5, 2015
Visit Reason
This report is a revisit conducted to verify correction of previously reported deficiencies at Diversicare of Council Grove.
Findings
The report documents that the previously cited deficiency with regulation number 26-40-302 (b)(i)(ii)(iii)(iv)(c) was corrected as of 08/05/2015.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 26-40-302 (b)(i)(ii)(iii)(iv)(c) |
Inspection Report
Follow-Up
Deficiencies: 10
Aug 5, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report documents that all previously cited deficiencies were corrected as of the revisit date, with corrections completed for multiple regulatory requirements.
Deficiencies (10)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4) |
| Deficiency related to regulation 483.15(f)(1) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(a)(2) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.60(c) |
| Deficiency related to regulation 483.60(b), (d), (e) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 10
Inspection Report
Plan of Correction
Deficiencies: 11
Jul 15, 2015
Visit Reason
This document is a Plan of Correction submitted by Diversicare Council Grove in response to deficiencies cited during a prior inspection.
Findings
The Plan of Correction details corrective actions addressing multiple deficiencies including abuse policy compliance, care plan updates, neurological checks post-fall, restorative nursing programs, fall prevention measures, behavior intervention medication associations, medication storage security, cleaning procedures, and emergency call light installations.
Severity Breakdown
D: 8
E: 2
F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to properly report and investigate allegations of abuse, neglect, injuries of unknown origin, and misappropriation of resident property. | D |
| Inaccurate or outdated individual care plans for residents with moderately impaired cognition. | D |
| Care plans cited during the survey process were incomplete or not updated appropriately. | E |
| Failure to initiate neurological checks post-fall for residents with cognitive impairment. | D |
| Lack of resident-specific restorative nursing programs for affected residents. | D |
| Environmental safety issues including non-skid strips and walker equipment needing replacement. | D |
| Medications not properly associated with residents' targeted behaviors and lack of staff education on behavior interventions. | D |
| Failure to identify and review targeted behaviors and medication appropriateness with consultant pharmacist involvement. | D |
| Improper storage and security of medications in medication carts. | E |
| Inadequate cleaning procedures for resident rooms and improper use of cleaning products. | F |
| Lack of emergency call lights in shower areas and failure to ensure proper functioning of call lights. | D |
Report Facts
Deficiencies cited: 11
Dates of corrective actions: Jul 21, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paula Gant | Administrator | Administrator responsible for compliance and submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Irina Strakhova | Person who added and modified the Plan of Correction | |
| Director of Nursing | Director of Nursing | Responsible for care plan updates, neurological checks education, medication audits, and behavior intervention oversight |
| Director of Rehabilitation | Director of Rehabilitation | Responsible for restorative nursing program implementation and communication |
| Assistant Director of Nursing | Assistant Director of Nursing | Responsible for compliance with neurological checks and medication audits |
| Maintenance Supervisor | Maintenance Supervisor | Responsible for environmental safety and emergency call light maintenance |
| HCSG Site Manager | Responsible for housekeeping staff education and cleaning audits |
Inspection Report
Re-Inspection
Census: 64
Deficiencies: 10
Jul 7, 2015
Visit Reason
Health resurvey inspection to evaluate compliance with federal regulations including investigation of allegations of abuse, activities program adequacy, care plan revisions, fall prevention, medication management, infection control, and other regulatory requirements.
Findings
The facility was cited for failure to report an allegation of sexual abuse, inadequate activities program for residents, failure to revise care plans timely for multiple residents, failure to complete neurological checks after unwitnessed falls, failure to implement restorative nursing program post therapy, failure to maintain fall prevention interventions, failure to monitor effectiveness of psychotropic medications with targeted behaviors, failure to secure medication carts, and failure to follow infection control cleaning protocols.
Severity Breakdown
SS=D: 8
SS=E: 1
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to report an allegation of sexual abuse to the State Survey and Certification Agency. | SS=D |
| Failed to provide an ongoing program of activities designed to meet the interests and well-being of residents. | SS=D |
| Failed to review and revise care plans timely for multiple residents including falls, activities, behaviors, edema, and bruising. | SS=D |
| Failed to complete neurological checks after unwitnessed falls for residents with fluctuating cognition. | SS=D |
| Failed to follow therapy recommendations to implement restorative nursing program to prevent decline in abilities. | SS=D |
| Failed to ensure resident environment free of accident hazards and failed to maintain assistive devices and fall interventions. | SS=D |
| Failed to ensure drug regimen free from unnecessary drugs by not associating targeted behaviors with medications and monitoring effectiveness. | SS=D |
| Failed to ensure drug regimen reviewed monthly by pharmacist who reports irregularities; failed to identify lack of targeted behavior monitoring for psychotropic medications. | SS=D |
| Failed to secure medication carts; medication carts left unlocked with medications accessible when nurse not in direct visual sight. | SS=E |
| Failed to follow manufacturer's instructions for cleaning products and failed to disinfect frequently touched surfaces during resident room cleaning. | SS=F |
Report Facts
Residents sampled: 18
Resident census: 64
Medication cart unlock incidents: 2
Fall incidents: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Nurse | Named in medication cart unlock and medication administration observations |
| Staff Y | Housekeeping Staff | Named in failure to disinfect frequently touched surfaces during room cleaning |
| Staff HH | Named in activities program deficiencies and resident activity documentation | |
| Staff D | Administrative Nursing Staff | Named in care plan revision and medication monitoring interviews |
| Staff V | Direct Care Staff | Named in medication monitoring and resident behavior interviews |
| Staff Q | Direct Care Staff | Named in resident activity and behavior interviews |
| Staff P | Direct Care Staff | Named in fall prevention and care plan adherence interviews |
| Staff S | Direct Care Staff | Named in neurological checks and fall prevention interviews |
| Staff E | Administrative Nursing Staff | Named in medication cart security and restorative nursing program interviews |
| Staff K | Restorative Licensed Nurse | Named in restorative nursing program interview |
| Staff II | Physical Therapy Staff | Named in restorative nursing program interview |
| Staff GG | Therapy Staff | Named in restorative nursing program interview |
| Staff NN | Direct Care Staff | Named in fall prevention interview |
| Staff MM | Direct Care Staff | Named in fall prevention interview |
| Staff OO | Direct Care Staff | Named in fall prevention interview |
| Staff J | Licensed Nurse | Named in neurological checks and medication monitoring interviews |
| Staff L | Licensed Nurse | Named in medication monitoring interview |
| Staff Z | Consultant Pharmacist | Named in medication monitoring interview |
Inspection Report
Enforcement
Deficiencies: 1
Jul 7, 2015
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective August 5, 2015.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date of substantial compliance: Aug 5, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Named as contact and signatory related to enforcement and survey findings |
Inspection Report
Life Safety
Deficiencies: 1
Mar 4, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'E' level deficiencies, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Life Safety Code deficiencies at 'E' level, pattern, with no harm but potential for more than minimal harm | E |
Report Facts
Effective date for denial of payments: Jun 4, 2015
Provider agreement termination date: Sep 4, 2015
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Follow-Up
Deficiencies: 8
Apr 15, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected.
Findings
The report confirms that all previously cited deficiencies listed on the CMS-2567 have been corrected as of the revisit date.
Deficiencies (8)
| Description |
|---|
| Deficiency related to regulation 483.15(a) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.20(b)(1) |
| Deficiency related to regulation 483.20(d)(3), 483.10(k)(2) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.60(b), (d), (e) |
| Deficiency related to regulation 483.65 |
Report Facts
Deficiencies corrected: 8
Inspection Report
Plan of Correction
Deficiencies: 8
Mar 27, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The Plan of Correction details corrective actions taken or planned for multiple deficiencies including environmental repairs, staff education on incontinent pad use, care area assessments, care plan invitation processes, bowel movement protocols, medication labeling, and oxygen therapy management.
Severity Breakdown
E: 3
D: 5
Deficiencies (8)
| Description | Severity |
|---|---|
| Use of incontinent pads in recliners, chairs, and couches in living room areas. | E |
| Environmental issues including broken tiles, loose door knobs, rust-colored caulking, damaged flooring, stains, and holes in walls. | E |
| Incomplete Care Area Assessment Summary (CAAs) for resident #49. | D |
| Care Plan invitation letters not consistently sent and scheduling issues. | D |
| Bowel movement documentation and protocol compliance issues for resident #58. | D |
| Failure to keep environment free of hazards, including unsecured treatment carts. | E |
| Improper labeling and storage of insulin pens. | D |
| Improper storage and handling of oxygen therapy equipment and supplies. | D |
Report Facts
Dates of staff inservice meetings: 03/26/14 and 03/27/14
Date environmental corrections completed: 03/27/14
Date environmental corrections to be completed: 04/15/14
Date deficiencies to be reviewed at QAPI meetings: May and June 2014
Resident number referenced for bowel movement protocol: 58
Dates of documented bowel movements for resident #58: 03/14/14 X 2 and 03/17/14 X 2
Date Colace started for resident #58: 03/18/14
Duration for monitoring bowel movement validation report: 30
Duration for monitoring insulin pen labeling: 30
Duration for monitoring oxygen therapy compliance: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paula Gant | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Census: 61
Deficiencies: 8
Mar 18, 2014
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with regulatory requirements and to verify correction of previous deficiencies.
Findings
The facility was found deficient in multiple areas including failure to maintain dignity by leaving incontinent pads in common areas, inadequate housekeeping and maintenance, incomplete comprehensive assessments, failure to involve residents or families in care planning, inadequate care for bowel management, unsafe environment due to unlocked medication cart, improper labeling of insulin pens, and poor infection control practices related to nebulizer and oxygen equipment.
Severity Breakdown
SS=E: 3
SS=D: 5
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to promote care in an environment that maintains or enhances each resident's dignity by leaving unused incontinent pads in chairs and couches in living areas. | SS=E |
| Failure to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. | SS=D |
| Failure to complete Care Area Assessment Summary after admission Minimum Data Set assessment for one resident. | SS=D |
| Failure to invite resident and/or family members to participate in care planning meetings. | SS=D |
| Failure to provide ongoing monitoring, reassessments, and interventions for lack of routine bowel movements for one resident. | SS=E |
| Failure to provide a safe environment for cognitively impaired independently mobile residents due to unlocked treatment cart containing medications. | SS=D |
| Failure to ensure appropriate labeling of insulin pens in medication room. | SS=D |
| Failure to follow acceptable infection control practices regarding handling and storage of nebulizer and oxygen equipment. | SS=D |
Report Facts
Residents present: 61
Sample size: 11
Incontinent pads observed: 10
Days without bowel movement: 7
Insulin dependent diabetic residents: 7
Medications in unlocked cart: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Verified staff should pick up incontinent pads, lock treatment cart, and complete Care Area Assessments |
| Nurse F | Nurse | Verified Care Area Assessments were not completed and described family invitation process for care planning |
| Staff Nurse A | Staff Nurse | Verified insulin pens were not dated when opened |
| Consultant Pharmacist D | Consultant Pharmacist | Explained pharmacy procedure for insulin pens and importance of dating pens when opened |
| Nurse E | Nurse | Verified bowel movement monitoring and physician notification procedures |
| Administrative Nurse J | Administrative Nurse | Stated nebulizer equipment should be bagged after use and oxygen cannulas should be kept in bags |
| Staff Nurse H | Staff Nurse | Verified treatment cart should be locked when not in use |
| Nurse I | Nurse | Administered nebulizer treatment and was unaware of bagging requirement for nebulizer equipment |
Inspection Report
Follow-Up
Deficiencies: 1
Mar 15, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.25(h) with ID prefix F0323 was corrected as of 03/15/2013.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.25(h) previously cited |
Report Facts
Deficiency correction date: Mar 15, 2013
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 12, 2013
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection, focusing on securing harmful chemicals to prevent resident accidents.
Findings
The facility held an all-staff inservice on March 12, 2013, educating staff on securing harmful chemicals in locked areas to reduce accident hazards. Maintenance replaced two of eight push-button door locks and will monitor lock functionality monthly, reporting to safety and quality assurance committees.
Deficiencies (1)
| Description |
|---|
| Failure to keep harmful chemicals in a locked and secure area to prevent resident access and potential accident hazards. |
Report Facts
Number of push-button door locks replaced: 2
Duration of weekly monitoring: 60
Date of staff inservice: Mar 12, 2013
Date of Quality Assurance Committee meeting: Mar 21, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paula Gant | Administrator | Submitted the Plan of Correction. |
| Shirley Boltz | Contact for Plan of Correction assistance. | |
| Irina Strakhova | Added and modified the Plan of Correction. |
Inspection Report
Re-Inspection
Census: 64
Deficiencies: 2
Mar 11, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with safety regulations, specifically to verify the facility's environment was free from accident hazards and that residents received adequate supervision and assistance devices to prevent accidents.
Findings
The facility failed to provide an environment free from accident hazards for 10 cognitively impaired independently mobile residents, as evidenced by multiple unlocked cabinets and rooms containing harmful chemicals accessible to residents. The facility acknowledged the need to secure these areas and ordered new locks.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Unlocked clean utility room with accessible harmful chemicals including nail polish remover, nail polish, disinfectant wipes, germicidal detergent, and hairspray. | SS=E |
| Unlocked cabinets in hall B shower room and whirlpool room containing disinfectant spray bottles with warnings to keep out of reach of children. | SS=E |
Report Facts
Resident census: 64
Residents in sample: 23
Residents affected: 10
Nail polish remover volume: 10
Hillyard Q.T. disinfectant volume in shower room: 100
Hillyard Q.T. disinfectant volume in whirlpool room: 300
Lamur hairspray volume: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse C | Reported that the clean utility room should be locked and chemicals secured | |
| Administrative Staff B | Verified the clean utility room door was to be locked and noted the facility ordered a new lock | |
| Nurse A | Verified that unlocked cabinets containing disinfectant should be locked |
Inspection Report
Plan of Correction
Deficiencies: 4
N064001 POC 2S2J11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection.
Findings
The Plan of Correction addresses multiple deficiencies including inaccurate MDS assessments, medication administration timing errors, expired or unlabeled food items, and medication cart labeling and outdated medications. Corrective actions include staff education, audits, and ongoing monitoring to ensure compliance.
Severity Breakdown
D: 2
F: 1
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Inaccurate MDS assessments corrected and MDS Coordinator educated on accuracy. | D |
| Medication administration times for Gemfibrozil and Omeprazole changed to before breakfast as indicated. | D |
| Food items not dated or expired were removed; dietary staff educated on labeling and food handling. | F |
| Medication carts audited for proper labeling and outdated medications; staff educated on medication labeling and outdates. | E |
Report Facts
Audit frequency: 2
Audit frequency: 4
Audit frequency: 5
Course completion date: 2017
Course completion date: 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Paula Gant | Administrator | Submitted the Plan of Correction |
| Irina Strakhova | Added and modified the Plan of Correction |
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